1
PATTIE A. CLAY REGIONAL
MEDICAL CENTER
PRESENTS
2
JCAHO UPDATE 2000
3
COMMONLY ASKED JCAHO
QUESTIONS AND ANSWERS
4
LEADERSHIP
EMPLOYEE
ALL EMPLOYEES
LEADERSHIP
 Q.1
What Changes Can We
Expect at Our Next JCAHO
Triennal Survey ?
5
LEADERSHIP

First, all employees could be involved in the
survey since the JCAHO surveyors may
choose to come back during off shifts to talk
with additional staff members. Typically,
this will happen when surveyors are getting
mixed responses from staff or variations are
identified.
6
LEADERSHIP

Second, our survey schedule will be
changed to allow even more time to interact
with staff members and inquire further
on issues
that may show weaknesses.

These survey activities have changed:
7
LEADERSHIP
 Patient
Care Setting Visits have
been increased to 90 minutes
each & a minimum of 2 open
charts will be reviewed per unit.

8
LEADERSHIP
 Information
Management
Interview has been combined with
Medical Records Interview. More
open chart reviews in patient care
areas and less opportunities to
select specific closed charts for
review.
9
LEADERSHIP
Patient Care Interview
will concentrate on
issues picked up
during the survey and
will also include:

Anesthesia, Operative
and Other Invasive
Procedures

Patient and Family
Education
 Continuum of Care
 Medication Use and
Nutrition Care
 Ethics and Patient
Rights
10
LEADERSHIP
Special Interview/Issue Resolution or Patient
Unit Visit
 includes time to allow surveyors to resolve
any issues or spent visiting more areas that
were not on the agenda. Surveyors may
also use this time to review additional open
charts.
11
LEADERSHIP

Performance Measurement and
Improvement Interview combines the PI
Overview, PI Team Presentation and PI
Steering Committee Interview. Only 1 team
will present (we select the team) and it will
be limited to 15 minutes. The majority of
time will be spent discussing ORYX data
results
and improvements being made as
the result of this data
12
LEADERSHIP



Building Tour and Environment of Care
Interview have both been increased by 30
minutes each.
Tour 3 hours,
Document Review 2 ½ hours.
13
LEADERSHIP
Why are we having an
inservice now when our
survey isn’t until January
2002?
 Q.2
14
LEADERSHIP
 TWO

REASONS:
Mainly, the JCAHO is now
sending updates nearly every
quarter instead of annually. This
requires us to be more timely with
making changes and
communicating these changes with
all staff.
15
LEADERSHIP
 Second,
JCAHO is now conducting
a higher number of RANDOM
UNANNOUNCED SURVEYS!
16
LEADERSHIP

Q.3 What are the odds of Pattie A.
Clay Regional Medical Center being
selected for a random survey?
17
LEADERSHIP

A.3 We have more than 992,000 chances
that we will have a Random
Unannounced Survey than winning the
Kentucky Lottery!! Here is how it
works:
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LEADERSHIP


A3 UP TO 10% OF HOSPITALS
BETWEEN 9 - 30 MONTHS FROM
THEIR TRIENNIAL SURVEY ARE
RANDOMLY SELECTED FOR AN
UNANNOUNCED SURVEY.
So PAC is eligible now through July
2001!
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LEADERSHIP







GUARANTEED TOPICS INCLUDE:
PI: Aggregation/Analysis of Performance
Data
TX: Medication Use
TX: Restraint Use
MS: Credentialing
EC: Plans Design & Review the
Statement of
Condition
HR: Competencies and Evaluations
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LEADERSHIP

OTHER POTENTIAL TOPICS INCLUDE:
 SENTINEL EVENTS
 SERIOUS
MEDICATION
ERRORS
 PATIENT TREATMENT ISSUES
 REGULATORY ISSUES
 STAFF-RELATED ISSUES
 ISSUES OF PUBLIC CONCERN
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LEADERSHIP




Q.4 What is the Future Vision for
JCAHO for 5 or more Years Down the
Road?
A.4
JCAHO is currently working on
the following plans for the future:
INTEGRATION OF SELF-ASSESSMENT
ACTIVITIES
DIVISION OF ON-SITE EVALUATION
BROKEN DOWN INTO TWO (2)
SEGMENTS IN AN 18-MONTH
INTERVAL
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LEADERSHIP




USE OF OUTCOME/PERFORMANCE
DATA AS PROXIES FOR STANDARD
COMPLIANCE
CREATION OF FULLY AUTOMATED
ON-LINE INTERFACE
REDUCTION/ELIMINATION OF
ADDITIONAL SURVEY FEES
HOLDING SURVEY FEES AT CURRENT
LEVELS
CURTAILING OTHER
ACCREDITATION-RELATED COSTS
23
LEADERSHIP

INTEGRATING STANDARD
EXPECTATIONS INTO DAILY
OPERATIONS
24
LEADERSHIP
 Q.5
If we are having a
survey, what don’t you
do when approached by a
JCAHO Surveyor?
25
LEADERSHIP
Don’t attempt to hide,
ignore, avoid or run from them,
unless of course you are
involved in a patient care
activity which would prohibit
you from immediately
responding!
 A.5
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LEADERSHIP

In other words, go about your work
and be certain to greet the surveyor
(good morning/afternoon). Based on
past experience, the employees that
“dodge” the surveyors are exactly
the employees that they want to talk
to . So, don’t be afraid and remain
calm and friendly! RELAX ..TAKE
A DEEP BREATH!!
27
LEADERSHIP

To date, no hospitals have ever
reported any employee injuries
during a JCAHO survey! Just
remember they too are human
beings and it is not as painful as you
may think to tell them what you
know. Just in case you do panic, it
will still be okay if you don’t know
the answer, then tell them so.
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LEADERSHIP

Q.6
What is a mission statement?
 A.6
Any of the following answers
are good:
• It is the purpose of an
organization
• it stands for what we believe in/it
tells us where we want to be in the
future/it explains who we are and
what we do.
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LEADERSHIP
 Q.7
What does your hospital
mission statement mean to you?
 A.7
Any of the following
answers are good but you
probably have a much better
answer yourself!!! BE
PREPARED TO ANSWER IN
YOUR OWN WORDS!
30
LEADERSHIP

We serve a culturally diverse
population..which means we treat patients
from all walks of life, therefore, we must
respect their differences and meet their
special needs. (Examples: 1) migrant
workers who are non-English speaking, 2)
elderly patients who have difficulty hearing,
seeing , and may be frightened, alone,
confused etc. 3) young first time mothers
who may need more education and
emotional support , etc.
31
LEADERSHIP

Our mission statement tells me how
we define quality .which is providing
friendly service to our customers by
doing the right thing, the right way,
the first time. I help deliver that
quality by . (give a
simple example
of what you do that is good! Brag on
yourself!!
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GIVE YOURSELF A BLUE
RIBBON
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LEADERSHIP
MISSION STATEMENT
 We
work hard to be clinically
effective and economically
efficient..which means we can’t
be everything to everybody
.what we do, we must do well
and affordable
34
LEADERSHIP
 Our
mission statement tells me
our vision of “serving the
healthcare needs of people in
our region as we have become a
regional healthcare facility.
35
LEADERSHIP

Our mission statement tells me that we
value patients rights involve our
patients and families in decision
making regarding their care and
respect their ability to make choices
including end of life decisions.. We
must inform them of the risks,
benefits, alternatives & respect their
decisions
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LEADERSHIP
 Q.8 What
is your definition
of quality?
 A.8 We define quality as
providing friendly service to
our customers by doing the
right thing, the right way the
first time.
37
LEADERSHIP
 Q.9
Who are your customers?
 A.9
Everybody! Patients,
Families, Visitors, Physicians,
Co-workers within my
department and other
departments
38
LEADERSHIP
What is a “hospital wide
patient plan of care” mean to
you?
 A.10 It is a detailed document
that describes the services
offered in each department—
(scope of services), description
of department, location, hours
of operation, staffing plans, etc.
 Q.10
39
 This
plan is a policy # ADM010-040 throughout the
hospital, and is used by
management to plan for
improvements and/or changes
in the services we provide. It is
useful in making good patient
care decisions which is helpful
in strategically planning for our
future. Be sure you know what
is included under your
department section of this plan.
40
LEADERSHIP
 Q.11 How do you make
certain the same level of care is
provided to your patients
throughout the hospital?
41
LEADERSHIP
 A.11
Our staff and Management
develop collaborative policies and
procedures which allows various
departments to work together to
maintain consistency in processes
done in different locations of the
hospital. Ongoing communication
and interaction with other
departments is key to our success.
42
LEADERSHIP

(You need to be prepared for giving
an example of how something done is
your department that is also done by
others is performed with consistency
could be as simple as our
hospitalwide handwashing
techniques to minimize the spread of
infections, transporting DNR
information with all patients as they
visit different departments/units,
etc.)
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44
ENVIRONMENT OF CARE
LIFE SAFETY
EOC
LIFE SAFETY
 Q.1
Who is responsible for
safety at your hospital?
 A.1 All employees!! Safety
is an important part of every
employee’s job at Pattie A.
Clay Regional Medical
Center.
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EOC
LIFE SAFETY
 Q.2
What does
“Environment of Care”
mean?
 A.2 “EOC” is another
word for managing our
safety program.
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EOC
LIFE SAFETY
 Q.3
What is included in your
safety program at our hospital?
 A.3 Our safety program
consists of seven(7) areas which
is monitored/measured at all
times including:
47
EOC
 1)
LIFE SAFETY
General Safety:
Visitor/Patient Incidents
Employee Accidents
Common Space/Grounds Safety
48
EOC






LIFE SAFETY
2) Life Safety::Fire
3) Security:
Theft, violence, etc.
Workplace
Violence
4) Emergency
Preparedness:
Disaster
Tornado
Bomb Threat,
etc.





5) Hazardous
Materials and
Waste:
Right To Know
MSDS
Chemicals,
Radioactives, Gas
Explosives, and
Wastes
Mercury
49
EOC LIFE SAFETY

6)

7) Utilities Management:
Electric
Phones
Water
Sewage , etc.
Medical Equipment:
Patient Care
50
EOC
LIFE SAFETY
 Q.4
What is the goal of the
Safety Program at Pattie A. Clay?
 A.4
The goal of the program is
to promote a safe environment for
patients of all ages, visitors,
employees and all other people
coming in contact with our
organization.
51
LIFE SAFETY FIRE
 Q.5
What should you do if
you see smoke coming from
a patient room, a fire in a
wastebasket, or any other
signs of a fire?
 A.5 Follow the R-A-C-E
protocol:
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LIFE SAFETY




FIRE
R = Rescue all persons from the
immediate area of the fire.
A = Activate the alarm and dial 3373 to
report the fire.
C = Contain the smoke or fire by
closing all doors.
E = Extinguish/Evacuate by using the
proper fire extinguisher.
53
LIFE SAFETY
FIRE
 Q.6
Where are the fire alarm
pull boxes and fire extinguishers
located in the department?
 A.6
(Department-specific
answer required.) Know the
locations of fire extinguishers and
fire alarm pull boxes in your area.
(You should be able to point to
them 20 feet from an exit.)
54
LIFE SAFETY:
FIRE
Q.7
How do you use a
fire extinguisher?
 A.7 P-A-S-S:
55
LIFE SAFETY
FIRE

P = Pull the pin located between
the two handles.

A = Aim the base of the fire.

S = Squeeze the handles
together.

S = Sweep from side to side at
the base of the fire. Watch for reflash and use extinguisher again if
needed.
56
LIFE SAFETY
FIRE
 Q.8
Which extinguisher
can be used for extinguishing
fires involving burning cloth,
paper, or wood?
 A.8 The fire extinguisher
Type ABC, containing dry
chemicals; or Type A,
containing water.
57
LIFE SAFETY
FIRE
 Q.9
Which extinguisher can
be used for electrical equipment
motors, switches, and
flammable liquids?
 A.9
The fire extinguisher
Type ABC or Type BC
containing dry chemicals.
58
LIFE SAFETY
FIRE
 Q.10
Which fire
extinguisher should not be
used on electrical equipment,
motors, and flammable
liquids?
 A.10 Fire extinguisher Type
A that contains water.
59
LIFE SAFETY
FIRE
 Q.11
Where is the nearest
fire exit?
 A.11 (Department-specific
answer required.) Know the fire
exit route for your department. If
you are a person who works in all
areas of the hospital, know where
all of the fire exits are located.
60
LIFE SAFETY
FIRE
 Q.12
How would you
respond if told, “A fire has
broken out?”
 A.12 Literally, respond as if
there were a real fire. Initiate
R-A-C-E Protocol.
61
LIFE SAFETY FIRE
 Q.13 How often do you have
fire drills?
 A.13
Fire drills are held
quarterly, one drill per shift.
During construction, we will be
required to have one additional
drill per shift.
62
LIFE SAFETY
FIRE
Q.14
What is the
hospital code for a
Fire?
A.14
Dr. Red
63
LIFE SAFETY
FIRE
What does “Interim
Life Safety Measures” mean
to you?
 A.15 During construction,
additional life safety drills
must be conducted
 Q.15
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65
EOC
EMERGENCY PREPAREDNESS
EMERGENCY PREPAREDNESS
 Q.16
Where do you find
information regarding
employee responsibilities
during a disaster?
 A.16 In the Emergency Red
Manual which is located in
each department.
66
EMERGENCY PREPAREDNESS
 Q.17 What does Pattie A. Clay
Regional Medical Center
consider a “disaster?”
 A.17 Any situation which
would overwhelm our capacity
to safely manage the influx of
patients based on existing
staffing levels and available
resources.
67
EMERGENCY PREPAREDNESS
 Q.18
How do we test our
emergency preparedness
program?
 A.18
The Safety Committee
stages two (2) mock disaster
drills per year.
68
EMERGENCY PREPAREDNESS
 Q.19
Where is your
department’s Emergency Red
Manual located?
 A.19 Know where your
department’s Emergency Red
Manual is located.
69
EMERGENCY PREPAREDNESS
 Q.20
Can you describe your
role in the emergency
preparedness plans?
 A.20 Discuss this with your
department director and know
the answer to this question!
70
EMERGENCY PREPAREDNESS
 Q.21
Who is trained to
evacuate patients?
 A.21 Everyone is taught the
principles of evacuation
because all personnel might
be asked to help.
71
EMERGENCY PREPAREDNESS
 Q.22
What is your
responsibility during an
external disaster?
 A.22 Specific departmental
roles are defined in the Code
Blue Policy outlined in
Emergency Red Manual.
72
EMERGENCY PREPAREDNESS





• Q.23 What information should one
attempt to obtain from someone calling in
a bomb threat?
• A.23 Exact Language used by the caller.
Location of the bomb.
When explosion is to occur.
Type of speech of caller.
Background noise noted.
Gender of the caller.
73
EMERGENCY PREPAREDNESS
 Q.24 Who should be contacted
upon receiving a bomb threat?
 A.24 Administrator
Vice President of Patient Care Services
Security
Safety Officer
Department Heads
74
EMERGENCY PREPAREDNESS
 Q.25
What do you do if
someone, whether a patient,
visitor, or employee becomes
extremely agitated or
violent?
 A.25 Remain calm, allow
them to verbalize, keep
distance, keep exit open.
75
EMERGENCY PREPAREDNESS
Q.26
What is the
hospital code for a
Disaster?
A.26 Code Blue.
76
EMERGENCY PREPAREDNESS
Q.27
What is the
hospital code for a
Tornado?
A.27 Code Black.
77
EMERGENCY PREPAREDNESS
Q.28
What is the
hospital code for a
Cardiac Arrest?
A.28 Code 99.
78
79
EOC
MEDICAL EQUIPMENT
MEDICAL EQUIPMENT
 Q.29
Can you show me
where test sticker is located?
 A.29
Test sticker is located
on side of equipment or near
the PAC No.
80
MEDICAL EQUIPMENT
 Q.30
When new equipment
is bought or loaned to your
unit you should?
 A.30 Call the work order
line for a visual and electrical
inspection before use.
81
MEDICAL EQUIPMENT

Q.31

A.31 Put an out of order tag on it
and take it out of service! Call in a
work order or send directly to Plant
Operations/Biomed for service.
How do you report an
equipment malfunction?
82
MEDICAL EQUIPMENT

Q.32 Whose responsibility is it to be
certain the equipment you are using is
functioning properly ?
 A.32
It is your responsibility prior to
using equipment that it is working
properly. It is your
responsibility to
also adequately maintain equipment in
addition to removing equipment
from service and reporting it
promptly!
83
MEDICAL EQUIPMENT

Q.33
Where are the oxygen valves
located in your patient care unit?

A.33
(Answer will be unit specific.)
Review all areas of department for location.
84
MEDICAL EQUIPMENT
 Q.34
Who is authorized to shut
off the oxygen valves in the
event of a fire or another
emergency?
 A.34
unit.
Charge nurse on specific
85
MEDICAL EQUIPMENT
 Q.35
What is your specific role
in Code Pink?
 A.35
(This answer is department
specific. Ask you supervisor for
very detailed information.)
86
87
EOC
UTILITIES MANAGEMENT
UTILITIES MANAGEMENT
 Q.36
What happens in the
event of a utility failure (i.e.
electric, water, gas, medical
gas, or telephone)?
88
UTILITIES MANAGEMENT


We have backup electrical generators that
kick in within 10 seconds of a power
failure. In this situation, only the equipment
plugged into red, emergency outlets will
work.
In the event of a water outage, water will
be distributed by Central Stores. All
employees will make an effort to conserve
as much water as possible.
89
UTILITIES MANAGEMENT
 In
the event there is a natural gas
outage, the Maintenance
Department will shut off all
incoming gas valves.

In the event there is a medical gas
outage, call the Maintenance
Department.
90
UTILITIES MANAGEMENT
 In
the event of a telephone outage,
use security radios, pay phones,
runners, plant operations radios.
 We
have a “What If” list in our
department that we can refer to in
any of these situations!
91
92
EOC
HAZARDOUS MATERIALS
HAZARDOUS MATERIALS

Q.37 Where can the details about
every chemical used be found?

A.37 In the Material Safety Data
Sheet (MSDS) Manual. Each chemical
used in the department is in the
department’s manual. The Master
MSDS Manual is located in the
Security Office, Emergency Room and
Administration.
93
HAZARDOUS MATERIALS
 Q.38
Other than the Material
Safety Data Sheet (MSDS), where
can the hazardous material name
and hazard warning for that
material be found?
 A.38
On the container label.
94
HAZARDOUS MATERIALS
 Q.39
Do you use hazardous
materials in your area?
 A.39
(Department-specific
answer required.) However, all
departments should have an MSDS
Manual.
95
HAZARDOUS MATERIALS
 Q.40
Can you name at least two
hazardous materials that can be
found in your department?
 A.40
Ask your department
director to review what hazardous
materials are found in your
department.
96
HAZARDOUS MATERIALS

Q.41 What first aid measures are
necessary when working with the
hazardous chemicals found in your
department?

A.41 Check the MSDS for each
specific chemical in the MSDS Manual
located in your department.
97
HAZARDOUS MATERIALS

Q.42 How is your waste disposed of
in your department?

A.42 Medical waste is disposed of in
covered containers labeled with a
“Biohazardous Waste” warning label.
The container is then removed from the
department by Housekeeping and taken
to a central area for disposal from the
hospital by a contracted company.
98
HAZARDOUS MATERIALS

Q.43 What should you do if you
have a hazardous spill in your area?

A.43 Evacuate all personnel and seal
off the area as best as possible. Pull
material safety data sheet if aware of
chemical. Contact Plant Operations
Director, Eddie Beach, at beeper 2223291.
99
100
EOC
SAFETY MANAGEMENT
SAFETY MANAGEMENT
 Q.44
What committee is
responsible for the management of
the hospital’s safety management
program?
 A.44
The Safety Committee; Bo
Young; Materials Management
Assistant Director is the Chairman
of this Committee.
101
SAFETY MANAGEMENT
 Q.45
Who is the Safety Officer at
Pattie A. Clay Regional Medical
Center
 A.45
Eddie Beach, Director of
Plant Operations.
102
SAFETY MANAGEMENT
 Q.46
How are the safety activities
reported to Administration and the
Board?
 A.46
The minutes of the Safety
Committee are submitted to the
CEO/Board of Directors monthly.
103
SAFETY MANAGEMENT

Q.47 Who is responsible for
maintaining safe practices in the
hospital?

A.47 Everyone is responsible for
safe practice! Potential safety hazards
should be reported to your immediate
supervisor!!
104
SAFETY MANAGEMENT

Q.48 What type of
safety/environment of care training
have you had during the last twelve
months?
 A.48
On a yearly basis, all
employees attend mandatory retraining
on Fire Safety, General Safety,
Infection Control, Electrical Safety,
Body Mechanics, Hazardous Waste,
and Incident/Accident Reporting. In
addition, patient care employees attend
CPR training EVERY TWO YEARS
105
SAFETY MANAGEMENT

Q.49 Describe your hospital-wide
smoking policy.
 A.49
Patients are not allowed to
smoke in our hospital without a
physicians order to do so. The criteria
followed by our medical staff is
patients that are terminally ill and the
benefits of smoking outweigh the
consequences.
106
SAFETY MANAGEMENT

However, if the patient is unable to be
escorted outside, then arrangements are
made through the House Supervisor to
accommodate them in a patient room
with negative airflow.
 All employees are required to smoke
in the designated employee smoke area
only which is located by the employee
parking lot.
107
SAFETY MANAGEMENT
 Q.50
What type of incidents
should you
report?
 A.50
Any patient, visitor,
employee, or physician incident or
unusual happening. Fill out an
Incident Report obtained from your
supervisor.
108
SAFETY MANAGEMENT
 Q.51
How do you report an
employee incident?
 A.51 Fill out an Incident Report
immediately.
 Notify
your supervisor
immediately.
109
110
EOC
SECURITY MANAGEMENT
SECURITY MANAGEMENT

Q.52 What would you do if you are
suddenly involved in a potentially
dangerous situation?

A.52 Protect yourself and call for
help as soon as possible. Remain
calm.
111
SECURITY MANAGEMENT
 Q.53
How soon after
witnessing a security incident
should an Incident Report be
completed?
 A.53
As soon as the incident
occurs.
112
SECURITY MANAGEMENT
 Q.54
What procedure do you
follow when a theft has occurred in
an area?
 A.54
Whether hospital or
personal property, make sure the
item has not been misplaced. Alert
your supervisor. Fill out a Security
Incident Report. (The supervisor
will contact Security.)
113
114
HUMAN RESOURCES
ALL EMPLOYEES
HR

STAFF COMPETENCY

Q.1
How do you maintain your
competency/skills in order to perform
your job?
 A.1
Educational Preparation,
competency checklists/skills lists, on
the job training, certifications, licenses,
etc.
115
HR
 Q.2
How were you oriented
to your job?
 A.2 Talk about all orientation
activities including: hospital,
departmental, unit, and jobspecific orientation.
116
HR

General Regional Medical
Center orientation includes:
1) Mission Effectiveness/
Continuous Quality Improvement


2) Proper lift and bending
techniques and other body
mechanics
3) Guest Relations and Patient
Rights/Advance Directives
117
HR
 4)
Infection Control issues such as
HIV/AIDS, TB, handwashing,
infectious waste disposal
 5) Environment of Care issues such
as: life safety, utilities, medical
equipment, general and safety,
security issues.
118
HR


6) Hospital History and
Structure
7) Human Resources Policies
and Benefits
119
HR
Department Specific Orientation:








Job Description
Policies
General Tour
Orientation Checklists
Job Specific Orientation:
Skill lists
Evaluation Conferences
Inservices/Continuing Education
Opportunities
120
HR

Q.3
Did you receive training
during department orientation on
equipment used in your area?
 A.3
Medical equipment used in
assigned areas were reviewed in
department orientation. New
equipment is in-serviced before used
and additional review of equipment is
periodically held.
121
HR

If I am ever unfamiliar with a piece of
equipment I can go to a co-worker with
training on the equipment, the
operators manual, our Biomedical staff
or my manager.
122
HR
 Q.4
What age of patients do you
care for? Have you received agespecific instructions and care for
all of these ages?
 A.4
If the ages of the patients
you serve are from birth - death,
you will need to give examples of
age-specific competencies you
have completed.
123
HR
 Q.5 How is your competency
measured?
 A.5 It is measured by
performance evaluations,
license where applicable,
general orientation for new
employees, competency based
orientation as appropriate and
continuing education.
124
HR
 Q.6 Do you have access to
educational materials related to
your profession?
 A.6 Materials are available
on the unit (textbooks, journals,
etc.), through Staff
Development, the Internet, and
other educational inservices and
programs.
125
HR
 Q.7
How are provisions made
concerning assignments that
conflict with your personal beliefs?
(for example, abortion,
sterilizations, blood transfusions,
etc).
 A.7
I would voice my concerns
to my manager who would in turn,
make arrangements for the patient
to be cared for by other staff
member as soon as possible.
126
HR

A7 (CONT)
I
would not abandon my patient
until appropriate arrangements
have been made. My patient of
course, would continue to receive
the proper care from me until I am
relieved of those relieved of those
responsibilities. See policy #
ADM-010-022.
127
HR
 Q.8
Who has the responsibility
of orienting borrowed equipment?
 A.8
My manager or designee
who borrows equipment has the
responsibility to provide their
employees the orientation
necessary to operate the borrow
equipment safely.
128
HR

A8 (CONT) Under no circumstances, do we
allow equipment to be delivered to our
department without making arrangements
with Plant Operations to perform a safety
check on it before it is put in use. I know a
particular piece of equipment is borrowed
when I see a yellow loaner sticker readily
available on the piece of equipment. I have
the obligation not to operate a piece of
equipment that is unfamiliar to me and
until I have received adequate training by
my manager or other individual giving the
inservice.
129
HR

Q. 9 HOW DO YOU ADDRESS YOUR
LEARNING NEEDS???

A.9

1. Attendance to continuing education
council (multi-disciplinary) to
determine what the needs of myself
and coworkers are for the upcoming
year.
130
HR

2. Attendance to inservice programs,
study packets etc. that provide me
with input on areas to improve upon.
 3. Access to television satellite
television with various programming
 4. Request to attend special programs
presented @ outside agencies.
 5. Self learning packets
131
HR
 Q.10 What are some examples
of training offered as a result of
a learning needs assessment?
 A.10
–. Computer Skills Classes on
Windows and Lotus Notes Lab
computer
–. JCAHO standards updates and
issues which are ongoing to our staff
132
HR
 Q.11
How is staffing decided and
adjusted?
 A.11 Typically, for inpatient
units, it is based on patient acuity
level. In non-patient care areas, it
depends on volume of work. (Your
supervisor can give you more
details)
133
134
PERFORMANCE
IMPROVEMENT
ALL EMPLOYEES
PI
 REVIEW HOSPITAL CQI
EDUCATIONAL BOOKLET FOR
BASIC UNDERSTANDING OF
QI AND OUR PROBLEM
SOLVING PROCESS: FOCUSPDCA!!
135
PI
 Q.1 How do you have input
on what should be improved in
your area?
• A.1Staff meetings, interviews, and
questionnaires are used to provide
input on our performance
improvement initiatives.
Department Directors also respond
to concerns addressed in the
patient satisfaction survey process
and discuss these issues in
department meetings.
136
PI
INPUT ON IMPROVEMENTS

Each department has their own
initiatives, based upon their core
process and data identifying
opportunities to improve. In addition,
any employee may suggest quality
opportunities which are chartered in
the Quality Improvement Steering
Committee.
137
PI
 Q.2
How does the Hospital
establish priorities for defining
which processes need to be
improved?
 A.2
The Quality Improvement
Steering Committee establishes
priorities based on input from staff,
patients, doctors and
administrators.
138
PI (ESTABLISHING PRIORITY)
 The
Quality Steering Committee
requires that teams to be chartered
must involve 2 or more
departments so that they are multidisciplinary! Many good
suggestions are submitted each
year, and even they are not
approved, they certainly can still
be projects to work on among the
departments involved!!
139
PI (ESTABLISHING PRIORITY)
 Priorities
are then determined
based on criteria including but not
limited to: high risk, high volume,
high cost, problem prone,
strategically important to the
organization, in-line with the
mission and values,
multidisciplinary nature of the
opportunity and the impact on
customer service.
140
PI

Q.3
What are some of the teams
and their priorities for 1999-2000:
 A.3 Team 1: Missing In Action:
Med/Surg/ICU/OB/Lab/Radiology/Hea
lth Info/Computer
• Operations/UR; focus on
improving availability of reports in
the inpatient’s current medical
record (ex: labs, xray reports,
H&P’s).
141
PI

Team 2: Double Trouble: Quality
Review/Computer Operations/Health
Info/OB/ER;
• Focus is to better utilize the available
space on present computer systems by
entering necessary data needed for state
requirements and performance
improvement into already existing
computer programs within the hospital
and making available for review to the
departments involved (should prevent
duplication of data collection).
142
PI
 Team
3: Three’s Company:
Computer Operations/Health
Info/Human Resources/ Staff
Development;
• Focus is similar to previous team as to
better utilize available space on present
computer systems within the hospital
and that would provide clinical
managers and department heads easier
access to necessary information
regarding employee competencies,
attendance records, staff education, and
143
CEU’s.
PI

Q.4 What were some of the
accomplishments in the past year?
 A.4
CONTINUOUS QUALITY
IMPROVEMENT (CQI) TEAMS
 Our CQI teams have made changes,
big and small, over the past year. This
year we elected to have only three
hospital wide multidisciplinary teams.
144
PI
EACH OF THE THREE TEAMS
 Strived to reduce inefficiency, cut
costs, and simplify work processes.
These teams have a greater
understanding and respect of each
persons role in achieving our goals
and fulfilling our mission.
145
PI

MISSING IN ACTION: Improved
the process of certain reports being
available on the inpatient’s medical
record. This allows for more efficient
healthcare planning by the patient’s
physician, nursing,
and other
disciplines involved in the individual’s
healthcare needs. This also reduces the
LOS by having all available
information present to determine
discharge planning.
146
PI
DOUBLE TROUBLE:
 Improved
the process of data
collection with present computer
operations within the hospital.
This helped reduce duplication of
data collection by different
departments including OB and
quality review.
147
PI
 THREE’S
COMPANY:
 This team has not completed it’s
goal yet, but is diligently focused
on the opportunity to improve the
communication Electronically
(computer) between clinical
managers, department heads,
personnel and staff development.
148
PI
 Q.5 What is everyone’s
responsibility in data
collection?
 A.5 Everyone is accountable
for information being accurate.
It is our responsibility to call
attention to apparent incorrect
data for collection.
149
PI
 Q.6 What quality initiatives
are in place in your department?
 A.6 Check with your
department director for specific
quality efforts, measurements
and also guest relations
improvements.
150
PI
 Q.7
What is your responsibility
in performance improvement?
 A.7
To ensure excellent
personal performance; to share
ideas about improvement in and
streamlining of processes; to
provide excellent customer service
and to listen to internal and
external customers
151
RESPONSIBILITY IN PI
 To
participate in basic
performance improvement
education; to participate in data
collections as requested; and to
participate on performance
improvement teams when
requested.
152
PI

Q.8
If our hospital should need to
scale down its efforts for any of
various reasons, what criteria would
the Quality Steering Committee use to
prioritize the minimal efforts to be
continued?
 A.8
As outlined in the Quality
Improvement Plan (Policy # QUR-001003), the following 3 criterion is used
to select the efforts to be maintained:
153
PI
 1.
Processes that affect 50% or
more of our patient population
 2. Processes that place patients
at-risk if not performed well
 3. Processes that have been or
are likely to be problem-prone.
154
PI

Q.9
Are performance improvement
activities carried out in a collaborative
fashion among departments and
various disciplines?
 A.9
Yes! (Be prepared to give
examples of how your department has
worked with one or more other
departments to improve processes).
155
PI
 Department
managers plan and
carry out improvement processes
with other departments—be
prepared to give 1-2 examples of
quality teams from last year and
their accomplishments as well as 12 examples of quality teams that
have just gotten underway this
year!
156
PI
 Hint:
BE SURE TO KNOW
ABOUT ANY TEAM(S) FROM
THIS YEAR OR LAST YEAR
THAT IMPACTS/IMPROVES
WORK IN YOUR
DEPARTMENT.
157
PI
 Q.10
How is data systematically
collected?
 A.10 Collecting data helps us to
assess outcomes or determine the
performance of a function or
process (i.e.; specific work tasks).
When data collection is systematic,
the data can be used to:
158
PI

1)Establish a baseline when a new
process is implemented
 2) Identify the performance or stability
of existing processes
 3) Measure the dimensions of
performance relevant to functions,
processes and
outcomes
 4) Identify areas for possible
improvement
 5) Determine whether changes
improved the process
159
PI (DATA COLLECTION CONT)

WE COLLECT DATA ON IMPORTANT
PROCESSES AND OUTCOMES
RELATED TO PATIENT CARE AND
ORGANIZATIONAL FUNCTIONS
ACCORDING TO PRIORITIES SET BY
THE QUALITY IMPROVEMENT
STEERING COMMITTEE.
160
PI


Q.11. Can you tell me something that your
department has improved from this time last
year? In other words, why would I want to
be a patient or customer of in your
department today rather than this time last
year?
A.11
You and your co-workers need to
tell the surveyors about any departmental
improvements, quality initiatives and/or
guest relations activities that have improved
your department in the last year.
161
PI

Be sure you know of any CQI teams that
have involved your department last year as
well as the new teams just underway for
this coming year. Also, if our patient
satisfaction survey has information
pertaining to your department, you need to
know what patients have viewed positively
and areas that patients have shown less
satisfaction and what you are doing as a
department to improve satisfaction in the
future!!
162
PI
 Q.12
What model is used by
CQI teams to improve
performance at Pattie
A. Clay Regional
Medical Center?
 A.12
Focus - PDCA
163
PI
 F(Find
an opportunity)
 O(Organize a team)
 C(Clarify current knowledge
of process)
 U(Uncover root problems)
 S(Start the improvement
cycle):
164
PI

PDCA

P(lan): Identify the problem, develop a
problem statement, collect data to
support solutions, use QI tools to
narrow the problem and decide on a
solution.
 D(o): Implement a plan, test using a
trial run, identify costs, people and
materials, educate staff.
165
PI
(PDCA)
C(heck): Monitor the plan’s progress,
obtain feedback, compare data with
original, use QI tools to monitor,
determine the success or failure of the
plan/action.
 A(ct): Incorporate the improvement
into policy, inform and educate all
parties, distribute new information to
all key players, look for new
improvements.

166
PI


Q.13 What education have you had in
Performance Improvement?
A.13 Management and/or employee basic
performance improvement in orientation;
CQI training for supervisors and managers;
team leader and facilitator classes for
selected groups of employees; advanced
training for CQI delegates and Steering
Committee Quality Improvement. For staff,
education is provided through “Just in Time
Training” when you participate on a
hospital CQI team.
167
PI

Q.14
How is Customer Satisfaction
Monitored?
 A.14
Through the development of
quality improvement measures; patient
satisfaction surveys, one-on-one
customer feedback, and interviews.
Results and actions are discussed in
Guest Relations Committee, Quality
Steering Committee, Management
Staff and Department Meetings.
168
PI
 Q.15 How is the same level of
care consistently assured?
 A.15 Through the Patient Bill
of Rights, use of Clinical Care
guidelines and medical
protocols (standing orders),
policies and procedures, Quality
Improvement activities.
169
PI
 Q.15
How is the same level of
care consistently assured?
 A.15 Through the Patient Bill of
Rights, use of Clinical Care
guidelines and medical protocols
(standing orders), policies and
procedures, Quality Improvement
activities.
170
PI
 Q.16 What
is the Performance
Improvement Plan for Pattie A.
Clay?
 A.16 It is our plan for
organization-wide participation in
continuously improving our work
processes to meet and hopefully
exceed customer needs and
expectations. See policy
# QUR-001-003 for specific details.
171
PI
 Q.17 What are your key
processes (important aspects of
care or service)?
 A.17 Discuss with your
Department Director the
specific work processes for
your area.
172
PI
What does “ORYX” mean?

Q.18

A.18 JCAHO requires all hospitals
to have a standardized system for
measuring performance and
outcomes. This system must be
approved by JCAHO. Our hospital has
selected two vendors to assist us in
being able to compare ourselves to
other hospitals (known as
“benchmarking”).
173
PI
 Our
Quality Steering Committee
has chosen the 7 following aspects
of care outlined below to measure
and assess for improvements, due
to their high volume in our facility.
Collectively, this represents 25%
of our patient population.
174
PI

There is going to be a move from Oryx
to Core Measures which will be
selected by clinical performance,
patient perception of care, health status
and administrative or financial
measures. An example of a core
measure that our hospital will be
involved in is Heart Failure.
175

Vendor: National Registry of
Myocardial Infarction (NRMI):
 Aspects
of Care to
Measure/Assess:
1. Aspirin usage within 24 hours
2. Door to drug time for acute
myocardial infarction
3. No initial reperfusion strategy
176
PI
 Vendor:
Indiana Hospital and
Health Association (IHHA):
 Aspects of Care to
Measure/Assess:
1. Readmissions within 30 days of
respiratory service
discharge
2. Primary cesarean sections
3. Repeat c-section
4. Total c-section
177
PI
 Q.19
What training have you had
on CQI?
 A.19
All employees receive CQI
training as part of mandatory
inservice as well as new employee
orientation. Also, if I serve on a
CQI team, then I would receive
training in my team meetings from
our team CQI delegates.
178
PI
 Delegates
are co-workers
that have received additional
training to help educate team
members on using FOCUSPDCA and the best tools to
assist us in measuring and
improving our team’s efforts.
179
PI
Q.20 What are “Sentinel Events”
and how should you respond?
 A.20
A “Sentinel Event” is defined
by policy (# ADM-010-026) when the
following events occur:

• The event has resulted in an
unanticipated death or major
permanent loss of function, not related
to the natural course of the patient’s
illness or underlying condition or the
180
event is one of the following:
PI (SENTINAL EVENT)
– suicide of a patient
– rape of a patient
– hemolytic transfusion reaction
involving the administration of
blood or blood products having
major blood group
incompatibilities
–surgery on the wrong patient or
wrong body part
181
PI
 When
the event occurs, as
applicable, first treat the patient as
directed by the physician. Second,
notify the Department Director or
House Administrator. They, in
turn, will notify the Vice President
of Patient Care Services, who will
coordinate an investigation with
appropriate staff.
182
PI
 When
the event occurs, as
applicable, first treat the patient as
directed by the physician.
 Second, notify the Department
Director or House Administrator.
They, in turn, will notify the Vice
President of Patient Care Services,
who will coordinate an
investigation with appropriate
staff.
183
PI
 Q.21 What
are clinical pathways
and how do they effect the
outcome of the patient?
 A.21
Clinical pathways are simply
a documentation tool that is preprinted, pre-approved, outlining
the course/plan of treatment for a
given diagnosis (ADM-010-025).
184
PI

The use of clinical pathways can:
• Reduce or eliminate system
breakdown
• Improve continuity of care
• Improve liability management and
outcomes
• Improve quality, reduce lengths of
stay, and reduce cost
185
PI
 Clinical
pathways are tools that
offer approaches to patient care
that assist in improving resource
utilization and promote quality
patient outcomes through reducing
variation among healthcare
practitioners.
186
PI
 Clinical paths are not:
 A substitution or replacement of
any physician’s professional
judgment In the care and
treatment of a patient.
 Standards of care.
187
PI

Q.22 How are clinical issues
identified?
 A.22 Clinical issues are identified by:
 Improved methods of diagnosis and
treatment of a significant related group
of patients (ex: COPD, CHF, chest
pain)
 Treatment of high cost diagnosis (ex:
respiratory failure)
188
PI

Treatment of high cost diagnosis (ex:
respiratory failure)
 Variation in outcome of healthcare
services (LOS variances, OB 2 day
vaginal
delivery stay)
 Requirements of regulatory,
accrediting third party payers, and
oversight organizations (HCFA,
JCAHO, BCBS, etc).
189
PI
 Q.23 What
are some examples
of clinical pathways at our
facility that have been
successful?
 A.23 Vaginal Delivery
Pathway, Newborn Pathway,
Newborn Jaundice Pathway,
Chest Pain, Post Partum Tubal
Pathway.
190
PI
 Q.24 What
are some clinical
pathways that we are working on
and planning to implement within
the coming year?
 A.24 Fractured hip pathway, SDS
pathway, COPD pathway, Csection
pathway, CHF pathway, Extension
of chest pain pathway that will
continue on telemetry or ICU.
191
192
MANAGEMENT OF
INFORMATION
ALL EMPLOYEES
MANAGEMENT OF INFO
 Q.1
What is your role in
managing information?

A.1 Protect Our Hospital Computer
System by following proper procedures
for protecting records and information
from tampering/damage, unauthorized
access or use and theft.
193
ROLE IN INFO MANAGEMENT
 Make
entries in a patient’s
record only if you are
authorized to do so.
 Never leave open files on your
computer screen or reports from
a printer unattended.
 Keep patient information
confidential.
194
ROLE IN INFO MANAGEMENT

For example: Get written
permission from the patient before
you share information with any
unauthorized person or agency. Do
not talk about patients in public
areas such as the elevator or
cafeteria. Never leave patient files
open or unattended where
unauthorized people could see
them.
195
ROLE IN INFO MANAGEMENT
 Keep
documentation up to date
and accurate. All entries should
be signed, dated and checked
for accuracy.
 Anytime you see how a process
can be improved, tell your
supervisor!
196
ROLE IN INFO MANAGEMENT
 Q.2
Where would you find
quick access to the poison control
information number in patient care
areas?
 A.2
The Poison Control
Information Number is located in
the automated phonebook located
through your phone system. The
poison control number is also
posted in patient care areas.
197
MANAGEMENT OF
INFORMATION
 Q.3 What
information do you need
to do your job?
 A.3
In general, information
needs to be timely and accurate.
For all departments, information is
needed during staff meetings,
mandatory inservices/orientation
and ongoing educational
opportunities.
198
MANAGEMENT OF INFO
For specific departments, basic
examples include:
Housekeeping: timely and accurate
patient discharge time
 Radiology: medical indication for a
patient having a procedure
 Laboratory: precautions for sticking a
patient

199
MANGEMENT OF INFO

CRC: information of if the patient has
an advanced directive
 Nursing: results of labs or exams
 Nutritional Services: patient medical
history for specific nutritional needs
 Patient Accounting: specific
information on the patients insurance
plan
200
MANAGEMENT OF INFO
 Q.4
What would you do if you
were not getting the needed
information to do your job?
 A.4
Staff and managers need to
communicate effectively.
201
MANAGEMENT OF INFO
 Staff has the responsibility to let
his/her supervisor know if there
is a problem.
 Management
has the
responsibility to determine if
the system can be improved to
provide staff with more timely
and accurate information.
202
MANAGEMENT OF INFO
 Q.5
From what sources do you
get information?

A.5 Memos sent to your department or via
pay stub
•
•
•
•
•
•
Bulletin boards and communication books/logs
Staff meetings
Other employees
Newsletters, etc.
Lotus Notes /Email
Web Site and Internet.
203
MANAGEMENT OF INFO

Q.6 What is knowledge-based
information?
 A.6
Information that is used in
problem solving can be found in
clinical, scientific and management
literature.
 On the patient floors are many
reference books, text books, drug
books, journals, etc.
204
MANGEMENT OF INFO
 In
the Staff Development office
there are additional textbooks,
reference materials and journals.
 In the medical staff library there
are journals, textbooks, reference
materials and other resources.
205
IM
 In
the computer lab and various
departments in the hospital,
employees have access through
their supervisor to access the
internet world wide web with
unlimited medical information.
206
207
MANAGEMENT OF INFO

One of your co-workers has
forgotten her computer password
and asks to use your password so
she can get her work complete.
What do you do?
Q.7
208
IM

A.7
Inform your coworker that you
cannot share your password as you have
agreed not to share your password with
anyone else by signing a form stating you
will keep your password confidential. You
suggest she see her supervisor to get her
password. If the supervisor is unavailable
you assist your coworker with her work or
find someone who can help her until the
password is received.
209
MANAGEMENT OF INFO

Q.8 You learn, as a result of your
work, that a close friend is on the
surgery schedule. Another friend asks
you what you know about this patient.
How do you handle the situation?

A.8 You do not discuss this patient
with your friend.
210
IM

Our policy states any Information
that is contained in the patient’s chart,
accessible by computer, or available
through any other written or
computerized source shall be
considered confidential, and shall not
be accessed, reviewed or discussed
unless such information is necessary
for completion of specific job duties.@
211
MANAGEMENT OF INFO

Q.9 What is the vision of our hospital
as it relates to Management of
Information?
 A.9 Our hospital has a Management of
Information Plan that outlines how we
are obtaining information through
networking in addition to the future
plans for our hospital.
• See policy # ADM-010-037 for
more information.
212
MANAGEMENT OF INFO
 Q.10
Is comparative data
available to assess performance?
 A.10
Yes, from Information
Management or the department
responsible for data.
213
MANAGEMENT OF INFO
 Q.11
Has your department or
staff been provided with proper
equipment and training to use the
equipment?
 A.11
Classes are offered in house
on a regular basis Information
Management can offer suggestions
for training and equipment needs.
214
MANAGEMENT OF INFO

Q.12 Are department and hospital
policies and procedures readily
available?
 A.12
There should be a paper copy
in every department.
 Current Policies are available
electronically in Lotus Notes. All
supervisors have access to this
database.
215
MANAGEMENT OF INFO

Q.13 How are you informed of
policy and procedure changes?
 A.13
Through staff meetings,
inservices and posting new policies.

Lotus Notes policy database will
have the latest policies. These can be
viewed, searched
and printed.
216
MANAGEMENT OF INFO

Q.14 When are you given initial
instruction and continue instruction on
how to access necessary data and
instructed on the confidentiality
statement?
 A.14
Initial instruction is given
during employment orientation
program and yearly during
inservice/continuing education.
217
MANAGEMENT OF INFO

Q.15 If you have access to
confidential information via computer
system, is it okay to leave it on this
screen while you attend to another task
away from this system?
 A.15
The proper procedure is to sign
off any screen that shows confidential
information. This way an unauthorized
person cannot access this information
while the PC is unattended.
218
MANAGEMENT OF INFO
 Q.16 Information on
hazardous material is located
where?
 A.16 In the Medical Safety
Data Sheet book located at each
work station.
219
220
PATIENT RIGHTS
ORGANIZATIONAL ETHICS
ALL EMPLOYEES
PT RIGHTS/ ETHICS

Q.1
What rights and
responsibilities do our patients have?
(ADM-010-002)
 A.1
RIGHTS FOR TREATMENT:
 Patients have the right to be treated
without discrimination. They cannot
be denied appropriate and necessary
services because of their race, religion,
national origin, gender or ability to
pay.
221
PT RIGHTS/ ETHICS

Patients also have a right to care that is
considerate and respectful of their
personal values and beliefs.

Patients have a right to appropriate
assessment and management of pain.
222
PT RIGHTS/ETHICS

ACCESS TO INFORMATION:
• Patients have the right to
review their medical record.
They also have the right to
have their questions about their
condition answered.
223
PT RIGHTS/ETHICS

INFORMED CONSENT:
 Patients have the right to know:
Treatment options including
alternative options and the option to
refuse treatment
 Risks, benefits and alternatives of each
option including the expected length of
recovery

224
PT RIGHTS/ETHICS
 Possible
side effects of
treatments and medications
 Costs
including what the
patient’s insurance may and
may not cover
225
PT RIGHTS/ETHICS

INVOLVEMENT IN CARE
DECISIONS:
• Patients have the right to be involved
in making decisions which includes
informed consent, withholding
resuscitative services, care at the end
of life and other options outlined in
various documents known as “advance
directives”.
• Patients also have the right to file a
complaint and receive help in resolving
226
any conflicts.
PT RIGHTS/ ETHICS
 CONFIDENTIALITY:
• Information about a patient
(medical records, test results, etc.)
must be kept private. Anyone not
directly involved in the patient’s
care, including family members,
must have the patient’s permission
to get information.!
227
PT RIGHTS/ ETHICS
CONFIDENTIALITY:
 Staff
must not needlessly talk about
a patient’s personal or medical
details! Be cautious of where and
how you discuss patient
information! Remember you
signed a confidentiality statement
upon employment that must be
taken seriously
228
PT RIGHTS/ORGANIZATION
ETHICS
 PRIVACY:
•
All care (examinations,
tests, etc.) should be given in
ways that respect the patient’s
dignity. Some examples of
how you do this should
include:
229
PT RIGHTS/ETHICS
Knocking before entering the patient’s
room
 Keeping curtains drawn during
examinations
 Discussing sensitive issues in a private
area
 Asking the patient’s permission to
speak about his or her condition in
front of visitors and/or family
members.

230
PT RIGHTS/ETHICS

ACCESS TO PROTECTIVE
SERVICES:
• Know our facility policy ADM010-032 addressing issues of
suspected abuse and neglect. All
healthcare workers are responsible
for notifying our Social Workers
(Kara Hill and Earlene Davis
Ext.3129 and 3166 ) when
suspicion of abuse or neglect
exists!
231
PT RIGHTS/ETHICS

PATIENT RESPONSIBILITIES:
•
These include giving accurate
information, following
instructions, asking questions
when something isn’t clear,
showing respect and consideration
for other patients, hospital staff
and visitors, and following
hospital rules such as visiting
hours and no smoking within the
building).
232
PT RIGHTS/ETHICS

Q.2
How is the patient informed
about his/her rights?
 A.2
The patient receives patient
information through our admitting
department ext. 3122 which
lists/explains patient’s services, rights,
and responsibilities.
233
PT RIGHTS/ETHICS

*During their hospitalization, if
patients have any questions regarding
their rights, please notify the
supervisor, who can access the
information for the patient. The
patient rights and responsibility
statements are also available in
Spanish.
234
PT RIGHTS/ ETHICS
How do you ensure the patient’s right
to confidentiality?
 A.3 Do not share computer password.
 Do not discuss patients in open areas
(i.e., elevators, cafeteria, hallways).
 Use caution when giving information
over the phone.
 Share patient information only with
appropriate staff.

235
PT RIGHTS/ ETHICS




Tear up papers that contain patient
information and place in recycling bins to
be confidentially shredded.
Do not use patient’s name when voice
paging MD’s.
Employees, volunteers, students and
affiliated care givers sign an agreement of
confidentiality at time of employment.
Only authorized individuals are permitted to
access records (Paper or via computer)
236
PT RIGHTS/ETHICS
 Job
descriptions/evaluations
address confidentiality.
 Boards or sign-in sheets with
patient’s address or diagnosis
should never be visible to the
public.
 Also, reclose doors/curtains to
maintain as much privacy as
possible with the patient.
237
PT RIGHTS/ETHICS
 We
provide pen/paper to our
patients if they seem embarrassed
or uncomfortable. We move to a
more private area when possible.
We assure patient gowns fit
properly. We close bathroom doors
when occupied, etc.
238
PT RIGHTS/ETHICS

Q.4
What is your role in obtaining
informed consent? (NUR-002-036)
and (NUR-002-037)
 A.4
The staff’s role is to verify
with the patient (by the patient’s
signature on the consent form) that the
patient has all the information needed
regarding the risks, benefits, and
alternatives of the procedure to make
an informed choice.
239
PT RIGHTS/ETHICS

Risks, benefits, and alternatives of the
procedure MUST BE ADDRESSED
BY THE PATIENT’S PHYSICIAN.
240
PT RIGHTS/ETHICS

If the patient has questions, the nursing
staff may choose to delay the consent
process until the physician has
satisfactorily answered all the patients’
questions and then proceed with the
consent process.
241
PT RIGHTS/ETHICS
 Q.5
What is an Advance
Directive? (ADM-010-016)
 A.5
A way for a patient to
decide in advance how he or she
wants to handle life-threatening
situations. Examples of AD’s are
Living Will, Health Care
Surrogate, Durable Power of
Attorney.
242
PT RIGHTS/ETHICS
 Q.6
What is a Living Will?
 A.6
An Advance Directive that
allows a person to specify his/her
health care decisions in the event
of a life-threatening condition or
terminal illness.
243
PT RIGHTS/ETHICS
 Q.7
What is a Durable Power of
Attorney?
 A.7
An Advance Directive that
allows a person to appoint
someone as their health care
surrogate to make all health care
decisions for them if they are
unable to communicate or make
decisions for themselves.
244
PT RIGHTS/ETHICS

Q.8
How are patients informed of
their rights regarding Advance
Directives?
 A.8
Upon admission, registration
personnel in the Admission office give
patients a pamphlet on Advance
Directives and ask patients if they have
an Advance Directives. If they do not
have an AD and want more
information or assistance in
formulating an Advance Directive,
they are referred to Social Services,
ext. 3129 or 3166.
245
PT RIGHTS/ETHICS

Q.9
What structures are in place to
address end of life decisions,
resuscitative measures or withholding
life-sustaining treatments? (ADM010-030)
 A.9
The staff act as patient
advocates and advise the attending
physicians of patient/family concerns
surrounding these issues. patient
support, as is the hospital Ethics
Committee.
246
PT RIGHTS/ETHICS
 There
is a hospital/medical staff
policy on DNR and end of life
decisions. Chaplain Service is
available for family .
247
PT RIGHTS/ETHICS

Q.10 How is organ and tissue
donation handled? (ADM-010-024)
and (ADM-010-034)
 A.10 Organ and tissue donation is
discussed with the patient/family in
appropriate cases. Refer to the Organ
Donation policy. The Kentucky Organ
Donation Association personnel is
available to the staff and family as
needed. If the donation is granted,
consent is obtained on the
Organ/Tissue Donation form.
248
PT RIGHTS/ETHICS

Q.11 How do you demonstrate family
participation in care decisions when
appropriate?

A.11 Participation is documented in
the plan/care map or standard of care
and in the nursing focus notes. Family
involvement is part of being a patient
advocate while maintaining the focus
on the patient.
249
PT RIGHTS/ETHICS

Q.12 How do we evaluate the need
for restrictions such as telephones,
mail, visitors, etc.? (ADM-010-043)
 A.12
Policies and procedures are in
place to govern restrictions which are
patient specific. When restriction of
telephone calls or visitors is deemed
appropriate, patients/families/friends
are educated regarding this decision
per policy on patient rights.
Patient/family/friend education related
to practice is performed on admission.
250
PT RIGHTS/ETHICS


Q.13
How does the organization ensure
patients’ care is not negatively affected if a
staff member asks not to participate in an
aspect of care due to personal, ethical,
cultural, or religious values? (ADM-010022)
A.13
There is a policy which defines
conditions by which employees can refuse
to participate in the care of a patient
because of cultural, ethical or religious
conflicts.
251
PT RIGHTS/ETHICS
 The
policy addresses the right that
employees have to request a
reassignment of work duties when
conflict arises. The manager and
employee evaluate this request on
an annual basis. The Human
Resources Department can assist
with questions if needed.
252
PT RIGHTS/ETHICS

Q.14 How do we help assure the
hospital conducts its business and
patient care practices in an honest,
decent and proper manner?
 A.14
The hospital has a Code of
Ethical Behavior (See Policy # ADM010-017) which addresses marketing,
managed care, billing and admitting
practices.
253
PT RIGHTS/ETHICS
 Hospital
staff have been
involved in developing this
policy that makes certain these
issues are all handled in an
ethical manner.
254
PT RIGHTS/ETHICS

Billing practices are monitored to
ensure that patients are billed only for
the services that were provided,
patients are given an itemized
statement and patient accounting staff
are available to answer patient
questions and resolve conflicts. The
hospital mission statement and annual
business plan care used as guides to
provide a consistent, ethical framework
for it’s business and patient care
operations.
255
PT RIGHTS/ETHICS
•.
•Q.15 Do we treat patients based
on their ability to pay for
services?
•A.15 No. We treat all patients
based on their need for services
256
PT RIGHTS/ETHICS
 Q.16 Who can look in a medical
record?
 A.16
Health care professionals
with a need to know and who
are involved in the patient’s
care.
257
PT RIGHTS/ ETHICS

Q.17 What has been done to
accommodate patients and visitors with
disabilities? (HRM-070-035)
 A.17
The hospital emergency room
entrance is designed for disability
entrance, disability restrooms,
elevators with Braille letters, and
general information in large print.
Other needed materials can be enlarged
on a copier or provided verbally..
Q.17
A.17
What has been done to acc omm odate patients and visitors with disabilities?
(HRM -070-035)
The hospital emergency room entrance is designed for disability entrance, disability
restro oms, elevat ors with Braille letters , and general information in large print. Other
needed materials can be enlarged on a copier or provided verbally.
258
PT RIGHTS/ETHICS
 Outpatient
registration area has a
TDD machine to communicate
with the hearing impaired. The
current list of interpreters who can
be called for deaf patients if the
need arises is available through Jo
Helen Cloys or the House
Supervisors office. All televisions
are equipped with closed
captioning. (ADM-010-015) .
259
PT RIGHTS/ETHICS
 Q.18
What has been done to
accommodate culturally diverse
patients and visitors?
 A.18 For non-English speaking
patients/visitors, arrangements are
made through the House
Supervisor for a translator to be
available. For patients with limited
education, staff communicate
various ways to make certain the
patient understands to the best of
their ability.
260
PT RIGHTS/ETHICS
 For
patients with certain religious
or cultural beliefs that prevent
them from seeking certain
treatments, procedures, etc. we as
healthcare workers respect their
rights to refuse treatment. For
elderly patients we communicate in
various ways to make certain they
see and hear what we’re saying..
261
PT RIGHTS/ETHICS
 Q.19
If you have an ethical
question on any aspect of patient
care delivery, what resources are
available to discuss the situation?
(ADM-010-027)
 A.19 There is a hospital Ethics
Committee. Contact the Vice
President of Patient Care Services;
Jill Cornelison ext. 3119, Shelia
Powell, Director of ICU/CCU, ext.
3550 or the House Supervisor.
262
PT RIGHTS/ETHICS


Q.20 How are you as a staff member made
aware of the ethical issues surrounding
patient care and the hospital’s policies
governing these issues?
A.20
A multidisciplinary ethics
committee exists and staff are made aware
through hospital policies and procedures,
mandatory inservice, orientation,
supervisors, patient guest handbook (given
at the time of admission), and
communications through the hospital ethics
committee. (Review our hospital policy #
ADM-010-027).
263
PT RIGHTS/ETHICS
Q.21 What is your department’s role
in the development and
implementation of the mechanisms
designed to address patient rights?
 A.21
All departments are
responsible for making sure that
patient’s rights have been respected
and departmental input is needed in
developing, implementing and abiding
by policies.

264
PT RIGHTS/ETHICS
 Departments
represented on the
Ethics Committee include:
ICU/CCU, Nursing
Administration, Social Services,
Community Chaplain,
Administration, Hospital Board,
Hospital Attorney and a
Professional Ethicist from EKU
faculty
265
PT RIGHTS/ETHICS


Q.22
How is the patient complaint
managed? (ADM-010-010)
A.22
The employee should clarify the
nature of the complaint before contacting
their supervisor, department director, house
supervisor or administrator on call. That
individual should promptly investigate and
analyze the situation and notify the
appropriate department director/manager for
assistance. All in-house complaints must
receive a verbal response within 24 hours.
266
PT RIGHTS/ETHICS
 Outpatient
and emergency
department complaints must be
responded to within five days. A
patient comment/complaint form
must be completed by the
individual responding to the patient
complaint and returned to Jo Helen
Cloys, Patient and Public Relations
Director, ext. 3446.
267
PT RIGHTS/ETHICS

Q.23 How are patients pastoral
(spiritual) needs met? (ADM-010-021)
 A.23
Our staff recognizes that
patients have spiritual needs and assess
their desire for such services. We have
an organized chaplaincy program with
minister call coverage for pastoral
visits or counseling. The spiritual
leader will document on the Pastoral
Care Notes and this is placed on the
patient record. Chaplains may discuss
spiritual care with the patient’s nurse.
268
PT RIGHTS/ETHICS
 To
protect the patients right to
confidentiality, each patient is
asked on admission if their name
can be given out to our Chaplains
on call.
269
PT RIGHTS/ETHICS
 Q.24
How do we inform other
departments that a patient being
transported to their area has a valid
advance directive or DNR orders?
 A.24 We always send the
patient’s chart with the patient.
The code status sheet is located at
the front of every chart and directly
behind the code status sheet a
living will is kept if one exists.
270
PT RIGHTS/ETHICS
 Q.25
What rights do patients have
regarding pain management?
(NUR-002-007)
 A.25 The patient has the right to
make decisions to manage pain
effectively and to have an
assessment of pain. Patients have a
right to information about pain and
pain relief measures.
271
PT RIGHTS/ETHICS
 Q.26
How is a patients pain
assessed and managed?
 A.26
The patient is asked about
pain level, location, description on
admission using a scale 0-5.
Policy and Procedures are in place
defining alternatives to help with
pain management.
272
273
SURVEILLANCE, PREVENTION
AND CONTROL OF
INFECTION
IC
(INFECTION CONTOL)
Q:1 Why is there an Infection
Control Department?
A:1 To reduce the risk of
infection between patients,
visitors and our employees
274
IC
 Q: 2 What single action is
recognized by the CDC (centers
for Disease Control and
Prevention) as the most
effective means of preventing
the spread of infection within a
facility
 A:2 HANDWASHING!!!!!
275
IC

Q:3
Who is responsible for
Infection Control?
 A:3
ALL of us at PAC are
responsible for preventing infections.
Kim Jarvis IC coordinator, Lisa
Gamble Employee health
Dr. Barnwell Chairperson IC
committee assist with this effort
276
IC


Q.4
What does the term “Standard
Precautions” mean?
A.4 Pattie A. Clay has adopted the
1996 CDC Isolation Precautions. Under
these guidelines, standard precautions
are used. Standard precautions mean
that blood, non-intact skin, and all body
fluids with the exception of sweat are
treated as potentially infectious, so we
must use personal protective equipment
to protect ourselves from being exposed
277
to these body fluids.
IC
 Q.5
What would you do for
an occupational exposure to
bloodborne pathogens (needle
stick, splash or spray to eyes,
non-intact skin)?
278
IC

A.5
Go through the needlestick
protocol. Report exposure to your
supervisor, then contact either the
Employee Health Nurse (Lisa Gamble),
the Infection Control Coordinator (Kim
Jarvis) or the House Supervisor to
complete an exposure packet which is
available from any of the above
individuals. The details of the exposure
will be reviewed with you and the risk of
transmission of a bloodborne pathogen
will be determined. At this point you will
be instructed further regarding any
action needed. Lisa Gamble will follow
279
up with you regarding the results of
IC

Q 6 What isolation system do we
use at Pattie A. Clay and what do
the signs mean?
 A.6
Pattie A. Clay Regional
Medical Center uses the CDC
Isolation Precautions
which
mandate standard precautions are
to be used at all times with all
patients. In addition to Standard
Precautions there are three
categories of transmission
based precautions:
280
IC (6)
THREE CATEGORIES:
Airborne - for TB, chickenpox or
other airborne disease.
 Droplet - for meningitis, pertussis,
influenza or certain other diseases.
 Contact -used for patients with
VRE, MRSA or other drug resistant
organisms.

281
IC (6)
Signs instruct visitors and other
persons to report to the nursing
station for information regarding
precautions to be taken before
entering the patient’s room.
Standard precautions are always
used in addition to transmission
based precautions.
282
IC

Q.7
What is personal protective
equipment? Name an example and
when you should use it.

A.7
Personal protective
equipment protects us from contact
with blood or body fluids. Gloves,
masks, goggles or face shields and
gowns are personal protective
equipment
283
IC

Q8
If a patient has an
infection which requires isolation,
where would you find information
regarding the type of isolation
required?

A.8
The Blue Exposure Control
Manual located in each
department, or Isolation policies
may be accessed via Lotus Notes.
284
IC

Q.9 What are items that go in Red
bags or Red containers?

A.9
Items that are full of blood
or have the potential to break or
splash blood go into the red
bagged waste containers. Needles
and sharp items which may
puncture bags go into the sharps
disposal boxes. This is called
285
IC


Q.10 Who monitors refrigerator
temperatures in our facility and what
action should be taken to correct an out
of range reading?
A.10
In the main facility temperatures
are checked daily and logged by our
Security personnel. Any variance is
reported to Plant Operations. Our off
campus facilities assign clinical staff to
monitor refrigerator temperatures and
report any variances to Plant
286
Operations.
IC

What immunizations are available
to our employees?
 A.11
All of our employees are
offered the Hepatitis B vaccine.
MMR (measles, mumps, and
rubella) and varicella (chickenpox)
are offered to employees who are
not immune to these diseases. All
employees are offered the flu
vaccine yearly.
287
IC


Q. 12 What precautions are taken for
patients with known or suspected TB?
A.12
The patient is placed in a
private room with negative air
pressure, outside ventilation and an
isolation sign is placed on the door.
Only rooms 429 and 431 on 4 West and
bed 2 in ICU are appropriate. The
employee flips the switch located
outside the room to turn on the second
fan which makes the room have
288
IC

An employee who has been fit
tested for an approved mask is
assigned to care for the patient.
Patients should not leave the room
unless required for testing or
treatment and then they must wear
a mask the entire time they are out
of the room. Only employees fit
tested with an approved mask
may enter the room.
289
IC
Q
13 Do you recap needles?
 A.13 Generally needles are
never recapped, but if there
should be a situation where
recapping is necessary then
you must use a one handed
scoop method or a mechanical
device designed for needle
recapping.
290
IC
 How
do you dispose of
sharps?
 A.14 Needle/sharps boxes
are where all
contaminated sharp items
are disposed of.
291
292
CARE OF THE PATIENT
CARE OF THE PATIENT

Q.1. Can restraints be initiated by
an R.N.?
 A.1. Yes, if the physician is not
available, with the approval of the
House Supervisor based on
appropriate assessment of the
patient and sound clinical
judgment. The physician must be
contacted for a written or verbal
order as soon as possible but
within 12 hours of the restraint
293
CARE OF THE PATIENT
 Q.2.
What must the physician
order include for the use of
restraints?
 A.2. a) The condition present
that warrants the use of
restraints.
b) Type of restraint
c) Time of the order
d) Date
294
CARE OF THE PATIENT
 Q.3. How long is a Med/Surg
restraint order good for?
 A.3.
No longer than 24
hours.
295
CARE OF THE PATIENT

Q.4. If a patient is restrained for
sudden aggressive behavior, how
soon must the patient be assessed
face-to-face by the physician and
how long is the restraint good for?
 A.4. If a patient exhibits sudden
aggressive behavior and poses an
imminent danger to himself or
others and restraints are applied, a
physician must see and evaluate
the need for restraint within ONE
hour after the intervention.
296
CARE OF THE PATIENT
A.4 (CONT)
Each written order for a physical
restraint for aggressive behavior is
limited to four (4) hours for adults,
two (2) hours for children and
adolescents age 9-17 and one (1)
hour for children under the age of
9.
297
CARE OF THE PATIENT
When the time span for the original
order is close to expiring, a nurse is
to telephone the physician, report
the results of his/her most recent
assessment and request that the
original order be renewed for
another period of time.....not to
exceed the time limits set by the
original order. The physician does
not have to perform another faceto-face assessment until the 24hr.
maximum is reached.
298
CARE OF THE PATIENT
 Q5.
What is a chemical
restraint?
 A.5. A medication that is used to
control behavior or to restrict
the patient's freedom of
movement and is NOT a
STANDARD OF TREATMENT
for the patient's medical or
psychiatric condition.
299
CARE OF THE PATIENT

The most difficult issue is determining
if the drug is being used as a chemical
restraint.
 Is giving a hospitalized ICU patient
Xanax prn considered chemical
restraint if they have never had a
history of anxiety?
 No- the doctor is anticipating that they
might experience anxiety in the ICU
setting .
300
CARE OF THE PATIENT
 What
about a hypnotic agent to a
teenager (no history of insomnia)
the night before scheduled surgery?

No- again, it is expected that the
patient might have trouble sleeping
being away from home and
worried about the procedure.
301
CARE OF THE PATIENT
KEY QUESTIONS to ask yourself
regarding drug orders :
 1. If the drug is given will it alter
the mood, mental status or
behavior?
IF the answer is yes ->CHEMICAL
RESTRAINT
302
CARE OF THE PATIENT

Does the patient have a history
of a condition or a new condition
which is usually managed by this
type of drug?
2.
IF the answer is yes -> this is not chemical
restraint
IF the answer is no -> this could be
construed as a chemical restraint
303
CARE OF THE PATIENT
Q. 6 NAME ALTERNATIVE INTERVENTIONS TO
RESTRAINT APPLICATION

SITTERS
 BEDCHECK SYSTEM
 FAMILY STAYING
WITH PATIENT
 FREQUENT TOILETING
 AMBULATION
 LEAVING LIGHTS ON
 SELF-RELEASE BELT
 NON-SLIP CHAIR MAT
 ADDRESSING
COMFORT NEEDS

ASSESSING
CONTRIBUTING
FACTORS;IE.MEDICATION
SIDE EFFECTS, ABN. LAB
VALUES,
O2




PT CLOSER TO
NURSE’S STATION
CONCEALING TUBES
& IV LINES
2-3 SIDERAILS UP
APPROPRIATE PRN
MEDS
304
CARE OF THE PATIENT


Q.7. Who is responsible for monitoring
resuscitation (Code 99) outcomes and
how often is this performed?
A.7. The house supervisor conducts a
review of all Code 99"s after the code
has ended. Completed sheets are
forwarded to Utilization Review with
reports presented quarterly at the
Nursing Management meeting and to
any affected area.
305
CARE OF THE PATIENT

Q.8. How can you be certain that a
crash cart on a different unit is
stocked the same as the crash cart
on your unit?
 A.8. All crash carts are restocked
by the pharmacy using the same
criteria for each and every crash
cart
306
CARE OF THE PATIENT

Q.9. How often does the pharmacy
check the contents of all crash
carts?

A.9. The pharmacy checks the
content of all crash carts on a
monthly basis for completeness
and expiration dates.
307
CARE OF THE PATIENT
 Q.10.
How often such staff
involved in patient care attend
the Code 99 Review inservice?
 A.10.
Every two (2) years.
308
309
CARE OF THE PATIENT
CONSCIOUS SEDATION
CONSCIOUS SEDATION
• Q.6 What is conscious sedation?
• A.6 A drug-induced depression of
consciousness during which patients
respond purposefully to verbal
commands, either alone or
accompanied by light tactile
stimulation. No interventions are
required to maintain a patient airway,
and spontaneous ventilation is
adequate. Cardiovascular function
is usually maintained.
310
CONSCIOUS SEDATION


Q.7 What is the difference between
“conscious sedation” and other types of
sedation?
A.7 Minimal sedation is defined as a
drug-induced state during which patients
respond normally to verbal commands.
Although cognitive function and
coordination may be impaired, ventilatory
and cardiovascular functions are
unaffected.(such as medication given for
pain or pre-operative medication).
311
CONSCIOUS SEDATION

Deep sedation/analgesia is defined as a
drug-induced depression of consciousness
during which patients cannot be easily
aroused, but respond purposefully following
repeated or painful stimulation. The ability
to independently maintain ventilatory
function may be impaired. Patients may
require assistance in maintaining a patent
airway and spontaneous ventilation may be
inadequate. Cardiovascular function is
usually maintained.(these patients will have
312
an anesthestist in attendance)
CONSCIOUS SEDATION
 Q.8
What equipment is to be
readily available in monitoring
the patient for conscious
sedation?
 A.8 The following equipment
and supplies must be available
for the administration of
intravenous conscious sedation:
313
CONSCIOUS SEDATION
 Continuous
monitoring noninvasive blood pressure and pulse
oximetry; and cardiac
monitoring (only if known cardiac
patient) during and immediately
following in the recovery period of
the procedure.
314
CONSCIOUS SEDATION
 *Continuous
intravenous
infusion of an appropriate
solution functional suction
apparatus with appropriate
suction catheters.
315
CONSCIOUS SEDATION
 Telephone
or some other
system so as to be able to
activate the emergency
medical system if required.
316
CONSCIOUS SEDATION
 An
emergency crash cart which
includes respiratory emergency
equipment.
 Reversal agents/medications.
 Sedation and analgesia medications
as ordered by M.D.
317
CONSCIOUS SEDATION
 Q.9 Who
is responsible for
assessing and/or reassessing
the patient immediately prior
to administering anesthesia
when a nurse anesthetist is
not involved in the
procedure?
 A.9 The independent
licensed practitioner.
318
CONSCIOUS SEDATION
 Q.10
How do you know if a
physician or other licensed
independent practitioner has
privileges to do a certain
procedure in your area?
 A.10 On every floor there is
a delineation of privilege
book
319
320
TX3
TX 3

Q1
How do you ensure
emergency meds are consistently
available, controlled & secure?
 A1.
Every shift, during normal
hours the department is open, the
staff verifies that the red numbered
lock is intact and that the lock
number matches that recorded
on the orange sticker affixed to
the cart. This shows that the cart is
complete.
321
TX3


Q2. What would you do if you found
that the emergency box or crash cart
was unlocked ?
A2. During pharmacy hours (8a-8p M-F,
8a-6p SS) call pharmacy. After
pharmacy hours, call house supervisor
to obtain emergency replacement cart
from night
cabinet. Red Box is to be returned to
Pharmacy via dumbwaiter when they
reopen (8am).
322
TX3

Q3.
How are medications
distributed, stored, secured?

A3. INPATIENT AREAS:
• Pharmacy uses unit dose
distribution system. Deliver a 24hr
supply of meds and
IV products
every day. Medications are locked
in carts. DEA scheduled meds
(Controlled substances) are
kept double locked
in carts or
323
cabinets.
TX3

OUTPATIENT AREAS:
Drugs routinely used are
kept
as floor stock. Once
used,
the charges are
sent to
Pharmacy for
replacement
and billing. Meds are kept
locked, controlled
substances
are kept
double locked.
Doses
324
TX3


Q4.
Describe how the medication
orders are processed for your hospital.
A4.
Practitioners write orders in
patient chart. Nurse verifies order and
order is copied onto med administration
record (medix). Copy or order goes to
pharmacy via dumbwaiter. Pharmacy
sends up enough doses until time of
cart exchange, when a new 24hr
supply is delivered. Pharmacy and
nursing reconcile drugs being delivered
at cart exchange against nursing medix.
Use chart to clarify discrepancies.
325
TX3

Q5.
How are pharmacy services
provided when pharmacy is
closed? Who has keys to
pharmacy?
 A5.
Per KY law, only
pharmacists may have keys to
pharmacy. After pharmacy
closes, night cabinet is
available to nursing supervisors
for new orders/admits
326
TX3
 Q6.
How are drug storage
areas checked?
 A6.
Pharmacy staff checks all
areas monthly for expiration
dates.
–
327
TX3

Q7.
How do you monitor the
effects of medications on patients?

A7.
Depends on the drug. If
analgesic, go back and ask patient to
rate their pain,
using pain scale. If
anti-hypertensive, take blood pressure.
If antibiotic, check
WBC, temp,
confirm C&S for bug and drug. Etc.
Overall there is a Multidisciplinary
approach
328
TX (7)
Multidisciplinary
 Pharmacy screens for drug-drug
interactions, drug-food interactions.
 Lab reports sub therapeutic or toxic
levels/labs.
 Everyone evaluates patient for
suspected adverse reactions.
 Nursing documents SE, effects.
 Physician , UR monitor outcomes.
329
TX3
 Q8.
Describe how you are
addressing the patient’s right to
pain management.
 A8. First of all, the patient is informed
of the right to pain management in the
admission brochure. Upon admission,
the nursing assessment is used to
assess pain. A standard pain scale (0
pain free-5 worst ever pain) is used to
document the pain..
330
TX3
Pain Management (cont)
 Medications are ordered by the
physician and administered
according to the instructions.
Appropriate selection and dose of
drugs are monitored by
pharmacists. When doses are
administered, the nurse re-checks
the patient and documents pain
after the analgesic dose (or nonpharmacologic) intervention
331
TX3 (8 CONT)

Care plans include the pain scale.
The physician is informed if the
pain regimen prescribed is not
effective at managing the patients
pain. In addition, PCA pumps are
now available at PAC. This
allows the patient to assist in their
pain management. Patients are
educated about their pain meds by
the nurse when given the med
and before being discharged home
on a pain med.
332
TX3
 Q9.
Are there any therapeutic
interchanges/drug substitutions
in place at PAC?
 A9.Yes.
Pharmacy &
Therapeutics committee has
approved several automatic
substitutions.
333
TX3 (9)






H2 blocker (po)= Zantac 150 bid (for
any oral H2 ; Axid, Pepcid, Tagamet)
H2 blocker (iv)= Pepcid 20mg iv q 12h
( for any inj H2)
Proton pump inhibitor= Prevacid
15mg qd (for Prilosec 20mg)
Antacid= Maalox Plus (for Mylanta)
Maalox Plus XS (for Mylanta II)
Multivitamins= Theragran M qd
334
TX3
 Q10.
How are those
substitutions
documented?
 A10. Pharmacy sends up
sticker noting interchange to be
placed in chart (with
order)Nursing unit staff is to
note drug patient actually
receiving on med administration
335
TX3
 Q11.
How long is a multiple
dose drug good for?
 A11. MULTIPLE DOSE VIAL
FOR INJECTION 30 days from
date opened, as long as not
visibly contaminated. Staff is to
write date and initials on vial
when opened.
336
TX3

BULK OR MULTI-USE
CONTAINER LIQUID, ETC
Up to manufacturer’s expiration
date as long as no visible signs of
contamination and proper
dispensing/administration
techniques are used
337
TX3
 Q12.
Where do you get the red
numbered locks for crash carts?
 A12. Pharmacy controls locks.
They sign them out in
Pharmacy. Issue with new
sticker for cart/box (with new
lock number).
338
TX3

Q13. How are samples used at
PAC?
 A13. Pharmacy does not keep
samples for inpatients. If a doctor
supplies samples for a patient,
they are delivered to pharmacy and
pharmacy will distribute via normal
cartfill procedure. Profile reflects
339
TX3 (13 CONT)

INSTANT CARE & MIDWIFE:
samples are logged into stock upon
receipt. Log reflects lot & exp.
dates. Samples are labeled and
dispensed by practitioner to their
patients and labeled with
instructions. Documentation that
samples given is noted in chart.
340
TX3

Q14. How are herbal products
used
at PAC?
 A14. Pharmacy & Therapeutics
committee approved a policy that
states the PAC pharmacy will not
stock/dispense herbal products for
inpatients. Nursing assessments
do include a question for the patient
about use of herbal, food
supplements or OTC products at
home.
341
TX3

Q15. What has been done at PAC
to minimize risk of medication
errors?
 A5.Re-implemented cartfill
exchange
reconciliation.
Developed an IV potassium
protocol removed undiluted Kcl vials from
floorstock and crash carts.
 Standardized iv drip
342
TX3 (15 CONT)

Converted from heparin to saline
lock (flushes)
 Reduced drugs available in night
cabinet
 Focus articles in Pharmacy
newsletters on steps to reduce
med errors.
 Held CE program, “How to avoid
the Headlines: Medication Error
Prevention.”
343
TX3 (15 CONT)

Review of P&P for safety related to
med distribution,
administration,
dispensing
 Performance improvement looking
at prescribing (completeness of
orders)
 Evaluating house wide
computerized charting software

Analyze and trend medication
344
TX3

Q16. Is there an automatic stop
policy at PAC? How does it work?

A16.
Yes. It requires the practitioner
to re-evaluate the use of certain types of
drugs every 5 days and either re-order
(to continue therapy) or discontinue .
Antiinfective agents, inj
corticosteroids, controlled
substances.
Pharmacy sends
notice to unit secretaries about drugs
which are reaching the 5 day limit and
345
they write note in chart asking Dr to
TX3
 Q17.
What MUE (medication
use evaluations) have been
done this year?
 A17. Allergy reporting, CHF, B
blocker+ ASA in post MI
patients, Epogen, Pain
management
346
347
CARE OF THE PATIENT
NUTRITIONAL SERVICES
NUTRITION


Q.: How are nutritional needs assessed
and monitored?
A: Patients are screened and if needed
assessed. The assessment includes a
plan of care, documented in the chart in
the multi-dis. plan of care. This plan of
care is undated and redefined
dependent on each individual patient
and their individual needs. Therapies
are monitored by nutrition services,
nursing, pharmacy and other
348
disciplines. These may include: intake,
NUTRITION


Q: How is nutrition services triggered to
see patients?
A: Each inpatient has a screening tool
completed by nursing staff to identify
problems on admission. The tool has 4
copies, one for the chart, one for
nutrition, one for social services, and
one for PT. This alters these disciplines
to review the charts. Nutrition can also
be consulted via physician, nursing,
pharmacy, other disc. or via discharge
349
planning group.
NUTRITION

Q: What happens to patients
needing trays between meals of in
off hours?
 A: Nursing may call down for trays
anytime during operating hours.
The trays are filled and placed on
the dumb-waiter.
 During off hours there are a variety
of food stuffs available on the
floors, juices, soups, Jell-O, frozen
350
NUTRITION
 Q:
What are you doing to
comply with HACCP guidelines
for enteral support?
 A: We use a closed system,
with RTH ( ready to hang)
formula when ever possible.
This allows the formula to be
hung for a 24 hour period.
351
NUTRITION
 There
are several formulas
not available in the RTH ,
these are poured into
containers, with enough for
only 8 hours at a time, the
containers are then rinsed
before new formula is added.
352
NUTRITION

We do not manipulate our formulas
with dye, but have color pelled
systems which allow the formula to
be colored without manipulation.
 Formula is dated and timed by
nursing. We also have an enteral
feeding form which alerts nutrition
to assess patients on enteral
support.
353
NUTRITION
 Q: Are
dietitians available
on weekends?
 A:
Yes, our dietitians
rotate weekends
354
NUTRITION
 Q:
How are you sure patients
get the correct diet?
 A:
Nursing services verify the
trays/ diet orders with food
service staff prior to trays being
passed. This is repeated for
each meal.
355
356
EACH OF US HAS THE
RESPONSIBILITY OF MAKING
SURE THAT WE ARE
KNOWLEDGEABLE ABOUT
THE INFORMATION THAT
HAS BEEN SHARED TODAY
“LET’S BE PREPARED”